An observational study of hypoactive delirium in the post-anesthesia recovery unit of a pediatric hospital

BACKGROUND

Hypoactive delirium is present when an awake child is unaware of his or her surroundings, is unable to focus attention, and appears quiet and withdrawn. This condition has been well-described in the intensive care setting but has not been extensively studied in the immediate post-anesthetic period.

AIM

To determine if hypoactive emergence delirium occurs in the recovery unit of a pediatric hospital, and if so, what proportion of emergence delirium is hypoactive in nature.

METHODS

We conducted an observational study using the Cornell Assessment of Pediatric Delirium in a cohort of 4424 children recovered at a tertiary pediatric hospital. The incidence of emergence delirium detected using the Pediatric Anesthetic Emergence Delirium (PAED) scale was also recorded for comparison.

RESULTS

There were 74 cases of emergence delirium detected during the study period using the Cornell Assessment of Pediatric Delirium (1.7%). Only 57 cases were detected using the Pediatric Anesthetic Emergence Delirium scale. The additional 17 cases detected using the Cornell Assessment of Pediatric Dlirium represent cases of hypoactive delirium. In this cohort of pediatric patients, 23% of all cases of emergence delirium were hypoactive in nature.

CONCLUSION

The significance of hypoactive delirium in this population is unknown; however, previous studies have shown that emergence delirium can result in post-operative behavior changes and may affect compliance with future episodes of care. However, hypoactive delirium is often missed without active screening. The prevalence detected in this study therefore suggests hypoactive delirium warrants further investigation.

Rare/cryptic Aspergillus species infections and importance of antifungal susceptibility testing

BACKGROUND

The number of patients infected with Aspergillus rose dramatically in recent years. However, studies on the clinical spectrum and antifungal susceptibilities of non-classical (non-fumigatus, non-flavus, non-niger and non-terreus) pathogenic Aspergillus species are very limited.

OBJECTIVES

We examined the clinical spectrum and antifungal susceptibilities of 34 non-duplicated, non-classical Aspergillus isolates collected from Hong Kong, Shenzhen and Shanghai.

METHODS

The Aspergillus isolates were identified by internal transcribed spacer, partial BenA and partial CaM sequencing and phylogenetic analyses. Susceptibility testing against eight antifungals was performed following the European Committee for Antimicrobial Susceptibility Testing's methodology.

RESULTS

The 34 Aspergillus isolates were identified as 14 different rare/cryptic species of four sections (Flavi [n = 8], Nidulantes [n = 8], Nigri [n = 17] and Restricti [n = 1]). Except for one patient whose clinical history could not be retrieved, 72.7% of the remaining patients had underlying conditions predisposing them to Aspergillus infections. The most common diseases were pulmonary infections (n = 15), followed by skin/nail infections (n = 6), chronic otitis externa and/or media (n = 5), wound infections (n = 2) and mastoiditis/radionecrosis (n = 1), while three were colonisations. Five patients succumbed due to the infections during the admission, and another two died 5 years later because of chronic pulmonary aspergillosis. Antifungal susceptibility testing showed that they possessed different susceptibility profiles compared to the classical Aspergillus species. The majority of isolates characterised were sensitive or wild-type to amphotericin B. The minimum effective concentrations for all the three echinocandins were also low.

CONCLUSION

Susceptibility testing should be performed for infections due to these rare/cryptic Aspergillus species to guide proper patient management.